Saturday, February 15, 2014

In case you're interested, I hate to exercise. I mean I really hate it. I do it anyway, in what's hopefully not a misguided belief that this is good for me, but I will be very unhappy if they ever decide that exercise is bad for you, having already devoted so much of my time to something I dislike. In any event, I've asked friends for suggestions for TED talks that I can listen to while I exercise, something to help the time pass as painlessly as possible. I was told to watch Einstein the Parrot, and if you haven't, Einstein was very entertaining, and I'm told I was cackling on the elliptical today. Here is a link for that short and amusing TED talk:

The other TED talk I listened to today was given back in 2001 by surgeon/writer Dr. Sherwin Nuland when he talked about his own experiences with Major Depression, psychiatric hospitalization, and electroshock therapy. I've embedded the talk above, and I hope you find it as moving as I did.

Wednesday, February 12, 2014

I want to point you to a psychiatry blog I happened upon not long ago, In White Ink, written by psychiatrist Dr. Maria Yang. There was a post that moved me, and I went to comment, but there was no place to do so.

Now, Dr. Yang is in the process of moving her blog and she's put up a post about My Brief History on the Internet. My favorite part of the post is where she marries one of her blog readers!Dr. Yang writes:

I started meet­ing peo­ple who read my writ­ing online. The inter­net was a dynamic and excit­ing place.
I started feel­ing ambiva­lent about writ­ing online. I closed down
com­ments because anony­mous peo­ple left state­ments like, “ALLPSYCHIATRISTSSHOULDDIE” and “YOU’RE A PSYCHIATRIST, YOUKILLCHILDREN”. A physi­cian who wrote a blog under a pseu­do­nym was revealed
in court. I wor­ried that my writ­ing wasn’t fic­ti­tious enough, that
maybe my sto­ries weren’t purely coin­ci­den­tal. My mind gen­er­ated
cat­a­stro­phes: Some­one might read a story and think I was talk­ing
about them! They would sue me and I would lose my license! Other
doc­tors would judge me! I would never recover! Even if I did, one of
those com­menters who hate psy­chi­a­trists would then kill me! So I shut down that blog. The inter­net was a scary and dan­ger­ous place.

At Shrink Rap, we've been to all those places, since we started blogging in Spring of 2006. We do have the best of readers, who are bright, articulate, and thoughtful, and we don't get death threats or personal accusations, but part of this post resonated for me.What we do see a lot of in our comment section are stories about people who are, from their point of view only (the psychiatrist's side is never solicited) who have been mistreated by the mental health system. I like getting the links, because I do like to know that these issues are out there. What I don't like, is the insistence that the patient is always the victim of the evil psychiatrist, that they played no role and if they behaved in an aggressive way that provoked unwarranted treatment, then it's obviously because the evil psychiatrist was not listening to their concerns and any reasonable, mentally well, human being would respond in such a fashion.

If that's not enough, then commenters go on to talk about how psychiatrists are all about "power trips." Trust me on this, any day a psychiatrist calls the police for an out-of-control patient, it's BAD day. There's no, "Honey, what a great day, I got to call the cops and commit someone." It's traumatic, upsetting, and draining for the psychiatrist. And, I'm well aware that it's traumatic, upsetting, and draining for the patient, and no doctor likes to upset their patients. It's a much better day when things are congenial and patients like the ways we have of helping them.

Personally, the psychiatrists I know -- who are all just people with the same types of flaws and imperfections that all people have -- really care about their patients, respect them as human beings, and are interested in working with them collaboratively. I get insulted when readers insist my career is about power trips and that I'm wrong to say we shouldn't revel in the stories of patient victimization without knowing the full story. I'm not saying that psychiatrists don't make mistakes, or that their aren't bad psychiatrists, and I'm certainly not saying that there are not bad laws out there, but I am saying that our field is not about evil people (they are the exception, not the rule), and power trips. One should reserve judgement when all sides can't weigh in. A psychiatrist simply can't tell his side of the story to the media. "I was hospitalized unjustly!" can't be countered in the media by a psychiatrist saying, "He insisted he was going to kill his family." What I'm lost for is why the "Psychiatrists are Evil" crowd congregate here at Shrink Rap. Do they think that the incessant drumbeat of "psychiatry is evil" in the comment section of a blog changes the world? It doesn't, it just annoys the bloggers and adds to this odd notion that a therapeutic relationship with one's doctor is adversarial, when we see it as being collaborative. It's exhausting and eroding. I believe that if the commenters want to change the world, they should start their own blogs for like-minded readers, and when they believe someone has been victimized by bad laws, they should write the newspapers and legislators in those states and protest the bad laws. The comment section of Shrink Rap does nothing, nada, zilch.

As mentioned, Delegate Murphy in Maryland has proposed a bill legislating Outpatient Civil Commitment here in Maryland. The text of the HB 767 is here. In it's current form, the bill is not likely to pass. Please remember, before you comment, this bill was written by a legislator, it is not coming from psychiatrists.On another note, there is another editorial by Dinah on Psychology Today's website about defining mental illness. It's not much different than the piece on Clinical Psychiatry News a few weeks ago, and with this, the topic of the Who Are the Mentally Ill? survey is now done.

Tuesday, February 04, 2014

Currently, there is a bill before our state legislature [video testimony] that would make it a crime for a therapist to have sexual contact with a patient. I wondered what our readers think of the idea of criminalizing sexual contact between a therapist and a consenting adult patient.

As it stands now, we all agree that it is unethical for a therapist to have sexual contact with a patient. Therapists are licensed to practice by professional boards (medical, social work, nursing, psychology), and all of these Boards handle complaints about sexual contact. They are difficult cases, because often the cases are one person's word against another's in a setting where there are no witnesses and no "proof." The sanctions include the loss of professional license, either permanently or temporarily, sometimes requirements for counseling and/or supervision, and a record of disciplinary action in a professional newsletter and details of the proceedings on the internet. The process includes a hearing, and the standard to sanction a therapist is lower than the standard of guilt for a crime. And finally, therapists are sanctioned for behaviors that are not generally considered "crimes," including any type of physical contact inappropriate to the therapist-patient relationship, even if the patient has been the one who requests the contact. So a therapist can be sanctioned for letting a patient sit in their lap or hold them if the patient insists this is what they really need, and the psychiatrist can permanently lose their license if a patient seduces them -- and we all agree that this is how it should be, the therapist is the one who is supposed to hold the boundaries. The ethics of the situation are dictated as such because the therapist-patient relationship involves an imbalance of power.

There have been references to patient-therapist contact as "sexual assault." Any type of forced sexual contact is a crime. The new law would extend the issue of criminalization would include contact with to competent, consenting adults. (I don't know the legal code, but I do assume it is already a crime to have sex with a compromised patient-- one who is psychotic, delirious or demented, just as it illegal to have sex with a "consenting" adult who is compromised at a frat party).

Obviously, sexual contact between an adult therapist and a minor is already a crime.

A patient who feels injured by a sexual relationship with a therapist can also file a civil malpractice suit against the therapist.

Here are my thoughts, and then I'd like to hear yours:

Using patients for sexual gratification is absolutely unethical. To deem such behavior with a competent, consenting adult to be a crime seems to me to say that the patient is not capable of any role in making the decision. It feels like it infantilizes the patient and I wonder what else this means that psychiatric patients are incapable of deciding?

Do we extend this to other situations where there is an imbalance of power-- so does it become a crime, punishable by jail time, to have sex with an employee ? Or an adult student? What about a patient who is not in therapy? (It's unethical and a cause for Medical Board investigation for any doctor to have sex with any patient). What if a surgeon has sex with a patient he knows has a psychiatric disorder? Should that be a crime, rather than an ethical violation?

It's a tougher standard to put someone in jail then it is to remove a professional license. In settings where "proof" may be difficult, especially since patients often come forward years later, will therapists be found "innocent" (because the evidence is not strong enough for criminal guilt), only to go unsanctioned?

The patient needs to testify in these hearings and such testimony in a closed hearing before a professional board may be easier for patients than hearings in an open court with an aggressive cross examination. Are there patients who would file a complaint with the board (this can be done on-line) who would not come forward if it entailed a police investigation and all the scrutiny that entails? Again, might unethical therapists go without censure? Will the police simply shrug, say there's no evidence if the event happened years before with no witnesses, and not prosecute?

What do you think? I understand that some states already criminalize sex with therapists. How is that going? How do these states divide what is matter for the police from what is a matter for their professional boards?

Saturday, February 01, 2014

When does some public good override psychiatric confidentiality? Dinah's post yesterday outlined the recent issue in the Navy's public release of the shooter's psychiatric treatment information. I wrote about this issue before following the release of the expert behavioral analysis panel's report on the suspected anthrax mailer, Dr. Bruce Ivins. In both cases, the rationale for releasing detailed information about the decedent's psychiatric care was cited as being a need to ensure that the government was taking appropriate steps to safeguard public safety. Following release of the EBAP report, the government---without admitting fault---agreed to pay 2.5 million dollars to the widow of the first anthrax victim.

As I commented on Dinah's post, in Maryland there is an extensive list of statutory execeptions to medical confidentiality:

with a patient's written consent

upon receipt of a valid court order or subpoena

in emergency situations

when a patient is dangerous

in cases of child abuse

during civil commitment proceedings

when the clinician is under investigation for fraud, abuse, or other criminal activity

when the patient puts his mental state at issue in a civil or criminal case

during hospital review, for quality control

when billing for payment, with patient's written consent

in case of an HIV-positive patient's high risk behavior

when the patient is incarcerated in an adult or juvenile correctional facility

when an involuntary patient elopes from a hospital

if an interested party files a missing persons report on a patient

if a patient is being served legal notice (process servers)

as part of a death investigation (release to medical examiner)

That last bit, death investigation, is what allows a facility or institution (or government branch in the case of the Navy shooter) to access postmortem records in most cases. Internal quality control and quality assurance are necessary processes that any health care system has to have. That being said, the results of a morbidity and mortality conference are not typically public documents.

In the case of the anthrax investigation, the EBAP report was originally sealed which meant that the report could not be read or redistributed by anyone without an explicit order from the court. The FBI, through the Department of Justice, was able to have the report unsealed. The results of the investigation were announced at a press conference and the report was put up for sale on the internet. Although the panel was careful to state that information drawn from medical records was redacted, the report gives explicit descriptions of Dr. Ivins' treatment history and psychiatric issues and strongly implies he had several motives to commit the crimes, although he was never indicted or convicted.

The parallels to the release of the Navy shooter records are a little uncanny. In both cases, the rationale for releasing the information is to address public concern that any preventive steps that could have been taken, were taken. However, there is also a strong whiff of CYA in both cases. After incorrectly accusing Dr. Steven Hatfill as the anthrax mailer the government was under pressure to close the case. After the EBAP press conference many media outlets published stories that Ivins was, in fact, the perpetrator.

Postmortem review is a necessary part of any health care system. However, I think we need to be clear that public release of that review should be subject to more stringent limitations.

With the adoption of electronic medical records and the
advent of CRISP, Maryland's centralized collection of health
information (it's an opt-out, if you haven't, you're in it, and if you
opt out, they still get your info, they just don't release it), I'm
coming to accept that there is no medical privacy. Before you get distressed, the system does not include physician notes -- it's tests per the labs, medications per the pharmacies, radiology reports, and perhaps hospital discharge notes. I'm not aware of any psychiatrists who are feeding information into the system, but if you're in Maryland and you're filling a prescription for a psychotropic, or getting a lithium level done, it goes into the system. Most doctors still can't access it, and the Emergency Rooms says the information is invaluable, in situations where people don't know what medications they take or what tests they've had, the information can be lifesaving. I, personally, wish that the system included patient consent, and some type of first-visit access grant, such as a ATM card with a PIN number, so that patients could be certain that only the people treating them have access to their records. Among the thousands of authorized users, misuse of the information is limited only by the honor system, and the fear of repercussions if caught. With that as a
prelude, The VA has posted the medical records of the Navy Yard Shooter
on line, with the names of the doctors redacted. The VA or AP did not feel inspired to redact the shooter/patient's name in the statement that was made in their release statement, but I have redacted it for our blog in abiding by our Shrink Rap policy to not use the names of mass murderers for fear that the publicity they receive creates a reason to commit such atrocities.

"The
Veterans Affairs Department agreed that the public interest in the mass
killing outweighed [the Navy Shooters’] privacy rights in keeping his treatment
records secret after his death."

The shooter is dead, his actions
destroyed the lives of many, the tragedy is obvious. But is "public
interest" (meaning 'curiosity') a reason to reason to forgo the usual ethical requirements established by the AMA before
scanning someone's medical/psychiatric records onto a public website and releasing them to the Associated Press? What do
you think? Perhaps the public has a right to know, but perhaps a
summary? Where is the precise line for public interest versus personal
health privacy? What other lines might be drawn?